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ompiled b : Penang Medical Post-graduate Group
Published by: Penang Medical Practitioners' Society

Th Medical Short An Examinatton

• •

Penang Medical Post-graduate Group:
HT Ong, IT Lim KPTeh WC Tan, CK Ong, SK Ma, RLC Loh, BP Ooi

Photos on cover: muscular dystrophy hyperthyroidism, arthritis. Photo above : internuc ear opthalmoplegia

erythema nodosum, rheumatoid

4_ f'iL1Ib]isher's

preface HlJ Ism, RVej;ayaJ~,,8S ,Lim

5_ f'or~wo[d by The Diirec1:o[General Of He arntb Mru;;;uYi~a ,AR Hasan
6 Foreword by

P,e:uaug Shde Director (!(ill Hea]Jtb,

1£ Ten;
7 ][nJtmdllilC'l.iimJJ::How' to use 'lbishDOk

HfOng

9_ Preparing :IIO[ l!hemedical short ease
HfOng.

ex:i'lirnt.iil.l~,fujo:U,

rru«

SK Moll

l3_ :Res,pi[OI!lmy SysteJliJ. CK' 01lg, AJW'Ra,zmr~RLC Loh si.
,/I,JJdOoIliteU

lJ'P Dot" ,iU, KW'l':iar;e:s:h DNW WV\til;g
p

89_ Ne1lim:i,]ogy 1T'Dun, GB'EOlLY; .A(; Hanifjah

[45_ 1iC000rdi,oRogy SK ,Ma, HI' Ong. 0' .RtJ.zaU H3_ DernJa.aJt)!J~Ggy l;viC Th~. I.C ,Cht;:m; 22.7 _ Eudoeriae aud! DhemLnOl!~o.logy KP''l'eh. 'IP' :ftlmllJ'
26l_

The Fimd,-year :medticarn sliriort ease KLC Loh, 'IP'feolW. Sf' Kew

2fj7 _ The UK. :PACES eX<l]ijjTIuaJt~oJ1l ,KLC LtJh, EEL Tsml.;g, SI'Kew
275 Wl1Ira't makes ,a geed I1itedi.c:etJ, trainee auda s,1l!lCressInrn deoter?

JS Ch!£'ah,HI' O~8

'll

.J'

AliIilh!lllfS::: OMig ChM Kh0!l11,n

Abdul R3rl3ikM~l!tit3llif Ljjd~, .!Che!l".R.[chianl U

Topics:
Res[pir.atom:yEsaminatien
Brenchieetasis T:ec~m~q]jlJle

Consolidatien
Interstitial Lung Disease

preuml :ru11il,:sioM.
TlJg)be]7Cn~osis crB) Bronchia] AsU:lrn;:[
Collapsed Lung (Ate]ed<l!~is) CJu:O!lJ!~C Qilb~!ill:iL]l)hVle R]~mo]i];<I!lJ' Disease «;000]

LtmgC:<mreI
Superior "VeutIJ CaiYtIJ Obstmction (SVCO)

Examine this patient's cites! and discuss yom findings.
!Di:a.;gtl:a::j:;;:: This patient has R I li. pleural effuakm if fl:l£'Idera:kJl<"I~e 3-i7:~ (e_!d. l.i1:cly ,a(:~[a]o~'_

[DW~tig::litiillU!

TM presence
.ii!.e

of a pleural diagnostic

~ff:us~oo and ita. I1a[l1I~ (e_2. ~3'-ema. Fbe ~[[e ~b.ot.r:il 'K selecredl

or haenictharaaj
J.C,OOr(jjlJ~ to

e;::tiiblii~d only by

[hJlrraCaCi~:1:t!e;ci"8.

I:b~

sesulja. 01 ~ If ib:: effnsinn Tb.ora:.:-,ntejji
.:',,ffltsion:::

preeedurea.
C;:J;J,

is small, tccraccoemeete

be :p:rl'OlDl.Vd ml.d¢! ultrasound

2ll.idla."'!.Ot:.

is inClk;ared in all
J1.-O~ E,~D~,';,I:e.aft.:;r

('~"I::l~

of' p~~mal eif:u-::.i.o1:1

oi unknown

ariern .aJ!.:iI, in
I

that do

-3,pprop_ri':j[!= g'~rw.e:n=t.

Ad!:ill.t:i.oJ:J::ill biop:3,Y proeedures, pfeurcscopy,

;;.iJ.C'h ~ c;~o::::¢liI,J1.C.C.dle ibioPiiY or :m:c:dio:::a1 ~.':j.oo:::oo,I;l'Y to confirm or ezclude ma]i2.'~la!l.t or ruherculeus

1.:o£1Ybe neeeeaary

eausea,
ELiru.i!ltarro!l. Fio.~;"go
R~l1G~ R~l1G~ C~Si 1~p'8Il:::iOJlJ
Q

of rl::~ pleural Ia ~
,iL'ld

:!!luio. is criticall lP'1..CUl!J!I1L'li1: cr is. it an '~m:~""(,~:!lli.l,? it is o:~mqne f it1JIlrid If it :i~ a.."T1. e:I1lpYO!llcjJ. cnr the pl~.m,':jI.:fl:uid.:p:H para-pneaancnic
.aJ1J

If >t:hor.e is aaaoclated

(en [~ affected :::ili)

fll.~td para-pneiancnic witha fm~'1 smell, are teu th~n clear

breathsounds vocal reaeuance and tacnfe "lOC'.iI. fieJcituB
Jl."O'[;::.~ to
Q

In,C.a.sC;;l!ihaf

of-<, .22 ~.2::ly

;i~1122~S:~

R~llG~

e~,-cll ~ tracheal
Q

complicated

effi:u.~LOll_ 'The two are odirti:rL:21~i;it:c:d by and aerobic, and fm TB
~11:i~aI

"Stony dill" percnasioa M,edj;:~:3:;:[L1."I·1 c[eV13."dOJl.: and ::.pez bear:

If >t:her~ is 110 a::::~aci;;_'k,dJ pn-OlllD.a!l.ia.:: • .I3 rbe [ll.~id a ~;m;5.~d..lte LL2bJfa cri[rna'"
"l!

o.pposi::e ride [I,p:oo,~rte

(oCfffi:-lilt

to tcll clmi:'-...aI:~y ez'::~

eandate?

.:iI~:3.1;,'l]."Ic;:,~:!!.t)

"Th,ach¢a iii &;o;f.iated <;0 ~ Sa"",[[=
Pt"OC.Ii!@dJ

iii.&'; (if k"l~e :plt"Llra] effiJ.riO,L1.)
upper level. 0; ItLo fl,tid

~JU!l for I!I!!icr'm::co.p¥ and! C;1.,iR~l1!e: both. anaerobic andculrnre, Ser.:-:iI, for c~-rolo:;:y. M.e;;_.gj_Tceprotein, Iaceare ~1Ly.dro2~lase ~H)

broJ.,obial ",eo;!!W,.e ""Y be:tLoJI<l.t!'!le

Q

Q

and [pH_

Lookfor
D

aseociared
[.jU

8!';:!1.S

mit::: rcay in-:il~c:.i:i,::e tl::~ cause of effuaderc

CT 8C'Em of ilJ.e Thorax
Q

Cachexle, c;:ICC.:JQDla

::::u.""tinht:2:. ~hlbhin:2:, raril~ari.on. b1irn and I}11.:iphcjJ~~!1.Op;;_thy ---·llill~ --- L~p"!J.al.:oa <Qe;.:jJe:l.:oi c~''I[:ilia.c faill.u:c ---

Th q;u_ii!:.'"!.~~ ~ p.Lc:iJrd. filiaid oo:rrecdo!l.. but alS/D [0< ('~:!!.e ~ liJJl.:~ ~¢I"OhVl1L:.i and :way ici.~,ti;fy ~U1.~m:::l;Iee:ted [iIJ.Il!D~l! or sclid :plell!l".al disease.

D
D

:Lj'""'IIl]?b.."Id.enQP_ai!J:}' I a.pktl.CJille.2:aly MasteC;t·rmlY ;i8;;[" --- tarcinmua Raised IVP.
SiJ.c:~;aI,

y".".t....OI1t
The t:Iea~.n.t Local
Q

D D D D

and p1dwon:;uy

of th-~ e~:3[on

&:P;::L1.d~

01',

ir1:e,c:a1i.t&e.

Ma1,~ rash --- SUE Rt.:.uwa.toiril,
Sj;:2ncB

ill.~.;iurue:nr ojnioae 'Th.o!~1i.ti~

in-o-l"Jde:

bm::ll :!!.O:iI;Ilk:~ ,--- :R...i!:I.. li.... disease er
f3.('j~ ---

'[]lor.i~e:L'iieai:3

of OOll:::crili.d-aJjoo --- PnCUlll_O:!i."I --- Hepatic i:aitnJ~

Q

Chea~ rube drai!rJa:ee Chemical :~:llelll{id.e8b S11r~~"I'1 intervention • Open (iJ.:J,
cQmp·~f~,t.:;.:iI,dIiJ'Sioo,
0.[

D Si:2IIIB of cl:ronk:
D D

Q

G.~~:::rari'ze.d I fa:±':j'11 :P'=':rtorb'ita1 o~::I;:::wa --- N~p-b![I[[C s:j-1~d!.o:l1J.e M:lf.I!X~m<i1[o.:.l-=S HnulllLyroidloS'w

Q

failed meotcel

treatment)

tb_o:r;K:--atom}' and decorrtcanons

fa!

~~c:ma.

Chapter 3::Abdomen
AIH.th.lllIrs::

Ooi! iBO{!ll Ph!llle K~.ulWaJres~lHaJj L~a:rn!IDail1:,uJJ IDawriaill \VOllJJg Nye"~oh

Topics:
AppfOaiching the aJbdi.o:uMnruJ1GI short case
Csreinoma Stomaeh

C~rul!:i.cLiver Disease

Splenomegaly
'TlfuatJiass,ruIDa
Renal 1!lZUllSiIP]arnl!

Hepatosplenomegaly
Lrver ""d. splenic enlargements geJle,raHy follow the same principles as ~le, illdividu'l e,nlmg"",enrs. Hower"", me, ~Q;lsible causes lIIoy be approached ill a.s lightly dil!fere,Dr mannea dep"nding on the other sig"' pre,eem, CausesrA1Mem;a
I) Myeloprolif"",dve 2) Ly'l1>pl",~olifer.u:ive

Inflammatory Bowel Disease
Th arrive lit tlie diagnosis of irill<:ltll1>itlo,), OOl<<eI ,ea,e through physicitU examination m ",imam 'my IIi"'''}, is challenging and requlrescollattng au penpheral sIgn. (w:t1ich somemues is minimal), Signs areeA1G€;~e'''1

disorders 3) Llver cmnests wit. portal :lIyp""ell'ion (100:1:.[0' erher signs of cnrontc li'i'Or disease); it i, however poo.iMe fm the paaent to be :plo~tori'c ill conditions when the cirrhosis i. a',,,,,eLated with hepatoma wii:l1 secondary polycythemia 4) S,or'.ge disorders (Ilie spleen is often ITilI(".l,",~e£) B):L'Imph""""op.1i:l1}' I) Infectious L1l011011l1clen,j, toxopl asmosis) 2) Ly'l1>pl"''''. 3) Ch'Oltic lymphocync Itl,V,."igMiol1' L) If liver CITrh03is is suspected, ulrrasonogram to assess live, appe.u .• nee, confirm .pl.eno",e.ga:~y and Iook for ascites,
1) II h>e",.mlagical a'pira;eft,epllille disQrde, is suspected, a full blood count, oload film, bone marrow or a 1~1llp:'node, biopsy

m""rd"",

Pale

(or

other

infecrions

lite

cyrcmegalcvirns

Ieukemia

Lnw bOG}' eeass rndex Or.al. ulcers s,.oUenlip. E,'denoe, of rreatment wim steroids ICmlllugoid, hype:nen'wm) E,'dBnoe, of treatment wim cyclosportne (gllffi IIypernoplI)', t1yperrensioll) Exm.-imllSTIn'" ",.nife,ration 1) MoutlI: Aphtous ulcers, sworlen lip" 2) Sl:in : EIyl:llelllil nodusnm, ~od""1>' .g<J.lg,enoBluu 3) Jaime Large joint anhritis 4) Eye: lI'veirn, episclenus.ccnjnncuvius 5) Ltver: Jaundire, wfld enlargement (tta'" primary sclerosing cllolangiti;j B)AMmnen Slugtcal scars or sroma sires Pa~p~hI.e masses (colonic tumor in ulcerative colitis, right il:i.ae fossa mass in Crohn's disease) Perimaldiseases (~de:m''''lIJ skin Iacg', fissunng. ulceration, ft:srnla formation) lLUiffeI'6l1'1iols I~ .",,,,,iiler I) Orohn'. disease : Ym';J<Oia. Iymph"",a,
2) tschenne

3) If inrection
mfection,

i, suspecred, ,1licklUlil, film, for L"ilIa,ia and serologies

for the suspected

tnbercnlcsis
radiation,

}wlaoa,gem.eillt Treetment will be based on ~'" aetiology,

Ulcerative, colin s : Infective, colitis (cam~y[obacle,r.cyt'ollleg.lovjr:lHJ_ are diJl",entials oreaeb.other.

Bolli Crrollll'S disease and ulcerattvecotlus Inv~,stigatiol1s I) Soo()l:micr",c()g»'
2)

""d.culmre

10 "",dude infecttve «113e R>I" . to monircr of smart bowe] and

full Blood Cou"tiC-re<Lcli,,, pro;oinlBr)'llrrocyte Sednuensation disease, acti'';.1ty andlcok toc possible anemia of chronic disease

3) Ab<!aminal obstmction

X-,,,y e
ill Cno!m'.

to

look for roxie dila .. non ill lie or evidence ballocnentercscopy disease

4) Sigmaido3COP}'iCoIOlloscopylDouble m,rological connnuatton, andextent 5) Bowel contrast s:mdtesJh1RI

: clossi~al"Ppearan.oe,

of

. strtcurres and! fisruli;"i8.

Ch ap
"',

,(,1['1'

••·t·,e··.·rl
.. ,'

4'· Neurolo•." y' g
" •.
N'

,.",

,',

"'il_

r

AlliIthl!ll['S:: LUII1,1',hie]JIJ Thien EllIlw rG:llIil'l: Bee
HaH!In;IlJ~1A'dllJ!~,
G~l~OO!l."

Topics:
CnmlaJ~Nerves: - Approach to unilateral ptosis - Approach ~o biruateraill!P'~OiS];s - R OClldomo~Ofnervepalsy (~edica1) - Internuclear ophfihaJlll1lop[egia - H~lanelra1, eranial nervepalsy VI - He]rs prulsy - ]3~laneml fac.~;tJJ]nelrVe palsy - HmThbMpaJIIsy - HmThbMpaJIIsy 2
Up"er liI~I'S: - Brachial plexus - SYlingomyoo:llJ

jnjlm![Y

- Mo:to[nelm![OOd1isease
- Hecker's museutar dlyst[oprfuly
LllIlwer~iIlI1ibs:

- PeK]Jl~e[a1 l],emopathy

- Charcet Marie Tooth
-Prutb]jl5Jo~l1':SDisease

- MycdlJ:mc d~s,trop~llY
- Cerebellar :syndlroMe - o]dpcmo

Examine tins patient's gait

6) Plantar response downgoing 7) No cerebellar signs 8) Stocking distribution sensory loss This patient has lower motor neuron lesion of the lower limbs with a motor predominant peripheral neuropathy secondary to Charcot Marie Tooth disease. How to proceed : 1) Observe the gait 2) Look for wasting of the lower limbs and deformity such as pes cavus 3) Check the tone of the lower limbs 4) Check the power (look for distribution of weakness e.g. proximal/distal) 5) Check reflexes, do reinforcement if absent reflex 6) Check plantar response 7) Palpate for thickened nerve 8) Check for cerebellar signs (heel shin rest if the lower limb is not too weak) 9) Check sensation (particularly for stocking distribution) Discussion : Causes of peripheral neuropathy(p1'edonlinantly 1) Guillain Bane syndrome (acme) 2) Chronic inflammatory demyelinating polyneuropathy(CIDP) 3) Charcot Marie Tooth/Hereditary Motor Sensory Neuropathy
4)

motor} (chronic)

Acute intermittent

porphyria

5) Lead poisoning 6) Paraneoplastic peripheral neuropathy Causes of peripheral neuropathy (predominantly 1) Diabetes mellitus WasTin.g of tile distal muscles ill Charcot Marie Tooth (Hereditary Motor Sens01Y Neuropathy) Diagnosis & Findings: 1) Bilateral foot drop 2) Wasting of the lower limbs (Inverted Champagne bottle sign) 3) Reduced tone 4) Distal myopathy 5) Absent reflexes 2) Alcohol 3) Uraemia in chronic renal failure 4) Drugs e.g. anti TB, chemotherapy agents, phenytoin, nitrofurantoin 5) Vit BI2 deficiency 6) Paraneoplastic peripheral neuropathy 7) Hypothyroidism
sensory}

Examine this patient's lower limbs

4) Look at the back for dimple, tuft of hair, a naevus, lipoma or scar in spina bifida
5) 6)

Examine

the gait

Offer to examine the anal tone

7) Offer to examine the upper limbs

Discussion :
Differential diagnosis : Spina bifida West nile virus infection Investigations: Nerve conduction Management Rehabilitation :

study and Electromyography

Wasting of the right lower limb
Diagnosis & Findings:
1)

Wasting of the right lower limb of the light lower limb of the right lower limb intact Weakness of the right lower limb Areflexia Sensation

2) Hypotonia
3) 4)

5) Plantar downgoing
6)

7) Upper limbs normal This patient has lower motor neuron involvement due to old polio. How to proceed: 1) Inspection toes 2) Examine 3) Examine for wasting, scars, burn marks, deformity e.g. pes cavus, clawing of the signs of the right lower limb with no sensory

tile tone, power, reflexes, coordination tile sensation

and plantar

Chapter 5: Cardiology
AiHth.!lIIIf'S:: M,~Soot Keug On:g: ",{'.aill TElk RazjJJ~i Om3r

Topics:
Ivlli.lra] reg1Iurgitalti.orD. Ivlli.lr;;d stenosis

Aortic [BgllI[;gil~l~.orD. Aortic stenosis

Pnlmonary stenosis
Pco:silbeN.c valves
Ve1llilrruc~]a!l oopta]. Ctl:eted (VSD)

Atrial septal defect (ASD) Pate1llilt DucmsAnesiosas (PDA) Tetralogy of Famot (mF)

Eisenmenger syndrome Dextrccardia
lrulfectiv€ endocarditis Hypenrophic obsllru.citiv€ c.Md.iomY0\paJthy (HOeM)

Introduction
Let me- start
offered famlllarlzed by

Severity

of MR! Signs of heart failure Signs of pulmonary Deteriorating before (S3 gallop. hypertension capacltv (this is evident in the station stem as it gives vital dues even "Pteose examine this lady who has; been short of ankle oedema, crepitations in the lungs)

saving that there are in fact limited variants of car dlovascular short cases that can be
short case examination variants or eg: final MD, final MMed of these or MRCP. One will need to be in order to excel in the all these comblnatlcn variants

in a structured with

1. 2. 3.

cardiovascular station.
I call them 1 the station "flavours" which consist of the following

functional the

touching

patient!

For instance"

breath on minjma! exertion
Causes of MR=

for 3 months duration"']

valvular

diseases Native Prosthetic heart diseases

a.
b.

"Ptease remember them well as the examiners would expect you tot 1.
2. 3. IHCM) pressure 4. pulses or venous Chronic Mitral rheumatic heart disease (still more common (wlth (with or without marfanold if

2

Congenital a.

exam t'

is carried

out in the

Asian reglonl+

Cyanotic

valve prolapsed e-ndocarditis muscle which

habitus)

b. Acvanotlc
Hypertrophic Isolated cardiomyopathy abnormal

Infective Paplllarv spondylitis

Hkelv ruptured

chordate) connective regurgitation tissue diseases as well) from various eg SLE, ankvloslng

dysfunction

(ie due to ischaemia, present with aortic

usually would

5

Others overview of the possible cases that could come out in a structured examination.

5.

Functional

lie secondary

to chamber

dllatatlcn
fantasy

in dilated

cardiomyopathy

causes)

This is really the general

Suggested

mnemonic:~ozy

_M:arry !nferfect

Case 1 I Mitral regurgitation
Station stem: the car dlovascular of presentation: regular at system of this gentleman with shortness of breath on exertion. Complkatiun ofMR= Please examine Sample record
W8<S

1.
2.

Heart failure Infective Atrial endocarditis

3. non-collapsing
a displaced There in na-ture. apex beat felt along was right ventricular the anterior heave murmur axillary line and P2. On 1.

flbrtllatlon

The pulse

60

bpm and

Examination sixth

of the precordium space. There

revealed were

Management

ofMR:

intercostal the

no thrills.

and palpable

auscultation, apex which

a" heart

sound was muffled.

There was a loud pansvstollc was 3/6. The pulmonary a trlcuspld

best heard over the of the second heart

Medical
;;'I,

radiated

to the- axilla. The intensity

component murmur

Diuretics

eg: Prusernlde eg: ACEi/ARB

sound was loud. Nonetheless Lungs were I would clear to auscultation that this

I could not appr-eciate and there

regurgitation

b. 2.

Vasodilators

Endocarditis Anticoagulation
oF

prophylaxis

was no pedal oedema. mitral regurgitation with evidence of pulmonary

3. 4..

if atrial

fibrillation patients; if EF

conclude

gentleman

has severe

Surgical

indication;

Symptomatic Asymptomatic,

hypertension.

He is in sinus rhythm

and has no signs of he art failure. hypertension • Mitral
tCfUID is still

c

50%, LV end-systolic > SOmmHg

dlameter

>

Snmm.

pulmonary

with systolic

pulmonary

pressute

valve repair or replacement cause
ormitraol

tne

conmceost

varcc tenens

in

me

region a, poatientswlth

previous

histar~

oturarc .a ted

rheum

.a ttc tover

wtth

heart

valve

Involvement ;In

grow up rnto their adulthood the- noccnco

and hence present rheumatic

wlth ...arlcus

vallluLar lesions, 01 which MR::ln,(j M:S.an~the in numbcr cnc hence the- commonest

commonest cause for MR \voLJld be MVP. which

aelvanced countries,

01LJnITNted

tcva

u dwlndlil"lg

m,;,l'tlo~undNdi,;,gnoYCdinoUffegion

Authors:

Chiang Chan Lei!?Cl!l!il1l!
'I~11l! Wool

Topics:
Alopecia Areata Cutaneous lLE SLE Erythema. Mwtif:o.rmel Srevens Johnson Syndrome/ Toxic Epidermal Neerolysis Herpes Zoster Lichen PillamllS Mycosis Fungoides Neurofibroma tosis Pretibial Myxoedema Tuberous Sclerosis Vilitigo Acanthosis Nsgriea«

BullousPemphigoid
Dermatomyositis Erythema. Nodosnm Leprosy Morphoea Necrobiosis Lipoidica Pemphigus Vulgaris Psoriasis Vasculitis

Investigations
1. CT I MRI Brain if indicated

Look at this patient's

leg and proceed

Treatment
1. There is no cure for NF. 2. Patient 3. Genetic with F should be followed-up and education large and examined every 6-12 months.

counselling

about NF is important, and painful can be cut out. to reduce the risk of

4. Neurofibromas malignancy

that become

and other complications.

Pretibial Myxoedema Proceed
From surface, inspection, nodules note the bilateral, asymmetrical, erythematous, finn, non-pitting verruciform oedema and plaques over the shin and feet. Thickened

of

both legs are also seen. 1) Examine the skin the skin morphology, distribution and arrangement (thighs, shoulders.

a. Describe hands) 2) Examine a. Goitre

the thyroid

gland for:

b. Thyroidectomy

scar

c. Emit
3) Examine the upper limbs and hands acropachy erythema palms and atrial fibrillation) weakness suggestive history of ophthalmopathy of thyrotoxicosis radioactive (exophthalmos, ophthalmoplegia, has had (pseudo-clubbing) a. Look for thyroid b. Look for palmar c. Wann and sweaty

d. Pulse (tachycardia e. Proximal 4) Look etc) 5) Ask for any personal or on any treatment, muscle

for evidence

and whether iodine.

01'

not the patient

in particularly

Chapter 7: Endocrine S: Rheumatology
Ao.t~ors:
l:ieIJF'I'V

Teh Peng (En~llOcdne)

Tan Bee El!lg I{Rheunmtology) Tell Kok Pemg (Endocrine 3nd. Rhetnn3to~.ogy)

TO'l)],CS:
Acromegaly Grave's Disease Hypothyroidism Cushing Syndrome Paget's Disease
RllilliellwmatoJld] Arthritis

Psoriatic Arthropathy
Osteoarthritis
GOUt

Ankylosing Spoadylitis Scleroderma 0[' Systemic Sclerosis SLE, Desmatomyosiris =refer to dermatology section

INSTRUCTION:
1. This lady complains of headache. Please examine her.

2. Check the UPPER and LOWER LIMBS for i) bowed long bone (humerus, tibial, femur) with increased warmth ii) signs of pathological fracture iii) osteoarthritis of big joints (knees) iv) check for signs of high output cardiac failure eg bounding pulse or pedal oedema 3. Check the BACK for: i) look for Kyphosis 4. Request to . i) compare current appearance with old photo ii) check urine for hematuria in association with urolithiasis iii) check fundus for - OPTIC ATROPHY and ANGIOID STREAK DISCUSSIONS: 1. How to investigate? i) Serum Calcium - normal ii) Raised serum ALP iii) X ray of skull and bones - lytic lesion in skull (osteoporosis circumscripra) - dense sclerosis of the long bones eg. Femoral head and neck region iv) bone scan 2. What are the treatments available? i) biphosphonates ii) calcitonin iii) surgical intervention as in fracture cases or osteotomy in severe malalignment 3. What are the complications associated with this disease? i) pathological fractures Ii) osteoarthritis iii) high output heart failure iv) renal calculus v) nerve compression (optic nerve and cranial nerve VIII) vi) spinal cord compression

Paget's Disease HOW TO PROCEED: I. Look at the HEAD and NECK for . i) Typically in older patient ii) big head size (enlarged skull) iii) short neck iv) any Hearing Aids? - deafness can be of conductive or sensorineural types v) feel the head scalp for warmness and bruits vi) elevated Jugular venous pressure - in heart failure

The Final Year Medical Short Case: W,ha.t Examiners Wallt
Thepurpose of short case eaamination is 10 test cGlmpetency GIll a c<ll!ldllidOl.Ee perform to a focused clinical eit:;ruDi.i.lllaJtiGl!ll!, a real patient under the S1lI!pBIV.is.icrJIl GJ[[ of'lTIlle exmn.eu., The c:;wii.d:id.aJte assessed 011 tfue basis 0:[ 'Iili.e'~eCll!mlqpll.e il filLe,exz'I.!IJ!)][iIllarUOl1larncl!aJlb~Eity is o the EOe:Elciil pbysic~d, signs aad interpret these findiugs c.oITec:llly..Central to the exaNium~Jtion is llie observatien of the srndeNlit [!ll!terOl.C!~:I1l;g w,irfblili.e patient. Sueh eompeteney can Gm'~y !be tested by demonenation and. not by v.e.rli:msiity or '!NID!tltenw!Drdis, as mora] or ,Ol.pe:r ex;ruDi.i.lllaJti!O!ll! s.. , Short case esaraination servesa mere feeused p'1ll[poseilhan ;ot traditional long ease eK;ruDi.i.lllaJti!O!ll!_ U!ll!like file long case, 'Iili.e c:_dirl.aJte has not had 'Wwle wi~ :[p:<lJtiellito' g.arm _y background rustOIY to the ease being exa!Lmm:~dlL TILe sfumlcaS'emECfIlJ!le~y assessesthe ;rlbjEiity of the candJi,oJ:arte peifornllar!ll!, accurate assessment and place :[p'h~lsj!l:::M, to :findii!ll!gs in ,oJ:atebeii!l.1(g '!TIlle oontext.. S[lOr1! case ,e:x.<'l!l1l1iuartion 1JJlSUilFrny' takesthe :IDOTIi.Lll ,canrl!i ofa tested over a sefeetion af real POl.'tieJi1J.Es wilili. p1lliy;ncairn signs_cl! overa r_ge all body syst~ms e.g. from cardioeascularto d.e[]]iJ;atol{)'gY,.

rill! the recent years, efforts 'by the various medieal edl:1l!Lcartioli1liis~s soug'l:l!t to ilT.JJIDp:rove have on. 'lie "!j!,alimJt.yand eonsistency of ,Rang and sliloItt: case eJrmW1Zifui.ans,., The :I][[OS'~ obvious development for short case isthe ,ii[urodiu.c.mo!ll!, f OSeE (ObjectiV-le Structured. e~imc:aR o EXa~!llii!ll!Zi,fu!'Oll) willi i1t:ll: variations. The :RmoJ:arme:!ll!ta'U change here isthe standardization oflJite iteNI'D.S being tested ,vilth:iiu each SM,iDrt case and elear aJ~GiCat[onof mark wei:ghta;ge ... PJSlO, the eJr;rulmner ,iis,silenced as farr as Ol.skiim,g Ill[Fee probmg ~lesticrJIls is ceneerned, for G it Oilb"i;ious!y increases 'tlu.eS1N!lb~ec.fui.v.ity;aw;tJ!:dii!ll!g .iiilJ!. marks, ..
Nevertheless, the :flJimcl!a~1lleJi1J.t<l!rn purpose of ;S;h,OItcase exarmiuZi.tioNl remains tile same. Therefore, wn:Ol.tfhe eXil!lT.ml.imer W3!!ll!ls.iis,;_ iNi'IDpart_t qi[]~moNl tID'ask in preparation for my forms IUf simt case examination,

O'!JiTIrich Mis.tOIl' of medicine has Ied to<l! standardized appm:ach to eX;MuiiNllng eardicvaseular, respiratory, ;Ol.bdJmuiinaR, eurclogical syst1em etc_ A~lhiDU.gM. variatiens n between teachers ;il!'iIJ!(l!, universities still exist, they are nUJ!La£diiEife:[lellces that reflect nldii:vi!(ilJ1JJmR preferences, A.:Ii1 eaperienced examiner sheuld 00 able to' discern 11ii:s:arncl!!ll!0~ I1ii16"'ike a fuss over ,iit It however caN!'be a soaree of WOIIY a!ll!d, oncern for same !ca!ll!dJi,oJ:artes, c undergradnates mme 'I:M;;t!!T.l postgndJua.tes.. Our advice is to stiekto wbat is generally accepted (inc,RllI.!ful:gillmse taru,ght :rnle:Klfuooks)arncl! seek, ,C]arllic;altii.an.w.iith senior teachers

THE UK PA'CES ,EX,AMINATION: SURVIVING THE STATIONS
Doctors 'Wis@wing~OleFlJiIlerspecialist iIlG1Jin~fl'8~]]UK need 110 pass the MRClP' (UK) lE-X.~1I.Mil'taifti:0!fIL ~ entry examinafion for speciaIDty training and is also recognieed in Urns Mtllays~~ as such. Uruwas ruJW(11Y:s. quite popular ~1I.10FlJ.g been doctors choosing the pfu1ys.licim path ..The final part oill this 'EruJ!mrnFlJat~,01l :~saclinieal component uOrv;']], asPAClE~S (MRClP' Part 2: arn1W~.cail Exatlli]'I!<][]oil.1I.) ]11 a:l1ld resembles a compromise between ij'uetradincnal long :and! :s'ruw.mt examination bwt is more similar to medical snort eases because oilltNi:edose case scrutiny of 'CIDrnlll]iCtll stillHs (incIDmiiil1l.ghistory takingand COmmDll1Cation) and the t~gbJt: ooetrol of time. As SlHCl1l, is a!p(p1rop[~a[e 00 included in Uris. t,E'OOtboOK it to ..Tmsd'ttl!pter .is. rant :~]WteilThdeda l(:ompl'eheil1l.s.1i.vetexl1 as about :PACES b!!l!t 11'0 l'DigWigbJtsome pointers for the Mtllays~~il1l.ctl.:l1lrndtlJ1!e:s they maketheir preparation. I1!l factt:Nte MRCP 'Official web:s~iIle as rnsexcellent and! has encHw,gfu, details to a.d!me:ssan concerns on lPACilES {see :[1I.1llp:! 1\\'ViW. mrepllJjk.olrgIPAOES). M:ud1l. 'Of the prepMat~an is S~mi1I.M totfuat of a.typical short ease exammation (also s:oocha!pte.r "Final yen :il.1I.1I.ed]c~] case: whaiJt:he €:X.aUil1l.€:lrS short t w~f'). \Vitiliw.tie avtl!~ltJJllirnlity 'Oflocal lPAOIES sitesm :Mtllays~.a.and Singapore, e~{liJ],dates 'CtllilJ. now aVO],dtravelling to UK 2m.{li ave somemoney. s

The obviousbenchmark for illi.e examiners is. whether the ctlll{lirndialteis ready 110 enter specialty training. This meansthat llie candidate s]]QlHld have sufficiently strmllg groundings onbis Drruweifmedicalknowledge, stillUs. and professionalism -e- to proceed fl!l!rtfue:r Theblanket qlJlesil!i'O!f]' is One1] asked is ~i'ketfutef'tfue examiners m(ndd,]ike llitllt to 'OlDerthe candidate the :posillimll In be his or fuer specialist registrar, 'The question SOOflTI.S harmless eI!lOi[].gilTh but it has stood the test oill 1lli'meas aFlJ. OVefMChi!]]I.g question llialt accllilirnte].y predietsthe candidate's readiness illm :s.peciaIDty training ..Tim (ij]i[]€sil!i'om evokes a cascade 'Of relevant queries in the mind of illie examiners like "Can I tlrustmm 'wiiitiliw. aID], my p.atll.elilliit:s ip].my absence?" "ills sfueoom]Jf:ltellJt enough 110 mC(!g1MZesiek patient eM]yT' "Win :ke know whelilli.and how to eonsaet me in .ap,prDpr],tlItetime and setting?" "Does she know howto deal willi {lirnftfillcu,mt patientsand not matell\M'iI.1I..gs orse T "Is he teaehable?" w "Is she a, pleasant person to :ruwave s my registrar?" "Does :~e actually c;o;mmllilimcaille a well?" Urns obvious therefore lli1l.atbollTh. linicaleompetence c and cmmnlJ.]]1J!ic.allrnoil1l. (i.e. pr:ese]W[.aJtioruiru'ogi[].€ willi examiners) Me cm:cl:ai1to stll1lisfy the examiners. d

Authors' Profile:
Datto' Dr...HjI. Abdel RazakMunalif graduated from University Malaya in m982. He obtained his Masters iin Internal MedJbc:ineiil11992 from Universiti Kebangsaan Malaysia and Masters in Respisatory Medicin.e from London University in 1994 ...Curremly.he is the director, Instirute of Respira tory Medicine ([fR) and NationalAdvisor fOT Respiratory Medicine Services, Minis~,ry of Health.Malaysia, Dr Chan Lee Chin graduated in m'987 from Universiti Sains Malaysia (Malaysia Science University - US1\.1),.She obramed her 1\.1CGPI FR.t\CGP in 1996 and Master nil Internal Medicme fun2001. She was gazetted as a. Dermatologist ]n 2003 and currently as a Consultant Dennatologist and. head of Department of Dermatology ]1I.1llPenang Hospital, Dr Bow Gaile Bee graduated in lli.998from Unsversiti S(lJHlS M,alays]a. (USM). She obtained her MRCP (UK) in. 200t., She trained ]1I.1llepilepsy at the Cleveland Clinic. Fcundatiea and is now consnltanr neurologist and head of Deparnnent of Nenrology in Penang General Hospital. Dr HaniffahAbdul Gafoor graduated fromUniversjti SainsMalaysia HI.1987...He obtained Ins MlRCP (UK) in 1990. He isnow aJ. Consultant Nenrologist in Island Hospltal and. AdjU11Ct Associate Professor with. Penang Medical College .. Professor Dato' (Mrs) Kew Siang Tong graduated from University of Smgapore in 1969 and obtained her MRCP (UK) ]1l.1llm'975. She is cnrrentlyProfessor of Internal Medicine and Dean of Clinical School, International Medical University, Kuala Lumpur, She oontinuea to practise as Consultant Physician and! Gasttoenrero']ogist She is a senior examiner, as well as a host examiner, for MRCP (UK) iPAC1jS. Dr Kumaresh Raj Lachmanan graduated in 2003 from the University of Malaya, He obtainedhis 1\.1RCP(UK) in 20 lli.O. e is now a clinical specialist in general medicine at H Penang General Hos,p~~Zll Thien Thien graduated in 21002frosn tile Universiti Malaysia Sarawak (UNIrvLAS) as a1l.1ll 1\1D."He obtained his postgraduate membership in Internal Medicine and awarded MROP (UK) HI.20007. He is now a. Clinical Specialist funNeurology ]1I.1llPenang General Hospnal.
DrLim

ProfesserLoh Li-Cher, Richard graduated from Royal College of Surgeons in Ireland in 1'991 and obtamedhis MRCP (UK) in lli.995.He completed his higher specialist training in Respiratory Medicine m.Londen in 20000 and obtained.his research MD from University of London in 2000 He is now Professor of Medicine and Head, Department ofMedicine, 1. Penang Medical College ...

Dr Ma Soot Keng graduated m 20{)2 from Universiti Kebangsaan Malaysia. He obtained his NIRCP (UK) in 2006. In 2010 he passed the US board examination to be a Certified Cardiac Device Specialist (CCDS). He is now a specialist cardiologist in Penang Hospital. Dr Dng Chao Khoon graduated from Universiti Sains Malaysia (USM) in 2002 .. She obtained her MRCP (UK) and M. Med (Int. Med) from the National University of Singapore in 2007. She is currently a fellow in respiratory medicine in Department of Respiratory Medicine, Penang Hospital, Dr Ong Hean Teik graduated in 1983 fromthe University of Malaya .. He obtained his MRCP (UK) in 1987 and his M Mecl (lnt Med) from the National University of Singapore in 1988. He is now eonsultant cardiclogist at HT Ong Heart Clinic. Penang, Dr Ooi Boon Phoe graduated from 1<1.S. amaiah Medical College, Bangalore University R in 1997. He obtainedhis MRCP (UK) mn 2004. Currently, be heads the gastroenterology Unit at Penang Hospital. Dr Razali Omar graduated ur 1986 from Universiti Kebangsaan Malaysia ..He obtained his Master in Internal Medicine (MMed) in 1993. He is now a consultant cardiologist and clcctrophysiologist at the Institut Jantung Negara and is also the Director of Clinical Electrophysiology and Pacemaker service at the same institution. Dr Tan Wcoi Chiang graduated from Universiti Sains Malaysia (USM) mn 2002. He obtained his Diploma in STD I HIV (COTTISA, Thailand) in 2005, Diploma in Dermatology (Glasgow) <md 1<~RCP(Ireland) in 2007. Curremly, he works as clinica] specialist in Dermatology, Department of Dermatology, Penang Hospita] .. Dr Teh Kok Peng graduated in 2003 from Universiti Sains Malaysia. He obtained his 11RCP (UK) in 2008 ..He msIlOW a. physician and getiatric subspecialty trainee. Dr Tsang Ee-Ling, Esther is a graduate of University of Malaya in 2003. She obtained her MRCP (UK) in 2009 and is now a Clinical Specialist in Penang Hospital. Dr Yeow Toh-Peng graduated from Trinity College, Dublin in 1997 and obtained her 11RCP (UK) in 2000. She completed her higher specialist training in Diabetes, Endocrine and Genera] Internal Medicine mnAddenbrooke's Hospital, Cambridge, UK ic 2()07 and is HOW Senior Lecturer of Medicine in Penang Medica] College .. Dr Wong Nye Woh, Damian graduated from University of Malaya in 1973 and obtained his fvllRCP (UK) fun 1977. He is consultant gastroenterologist at Lohguanlye Specialist Centre and an Adjunct Associate Professor with Penang Medical College.